Pediatric Developmental History



Early Life NutritionBreast fed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf Yes, indicate duration: monthsFormula fed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf Yes, indicate duration: months and formula type:Early DevelopmentDid patient:Walk by 17 months old? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownSpeak his/her first words by 12 months? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownSpeak in two word combinations by 2 years? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownSpeak in completed sentences by 3 years? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHave a cognitive/learning disability? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownAttend a day care group (with > 5 other children)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHas participant/subject ever had a menstrual period? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A – maleIf so, youngest age the female participant/subject had a menstrual period? yearsEducational HistoryType of educational services received: FORMCHECKBOX Special education FORMCHECKBOX Regular education FORMCHECKBOX Early intervention FORMCHECKBOX None FORMCHECKBOX UnknownHas the participant/subject ever repeated a grade in school? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownCognitiveIndicate patient’s cognitive status with regards to education: FORMCHECKBOX Above average (receives mostly As in school) FORMCHECKBOX Normal (functions well in school, receives mostly Bs, Cs) FORMCHECKBOX Minimal difficulty (struggling but obtains passing grades) FORMCHECKBOX Moderate difficulty (needs assistance with school work such as an Educational Assistant) FORMCHECKBOX Special needs class setting, actively participating in learning FORMCHECKBOX Severe (unable to function in regular classroom even in special class setting, not an active participant in learning activities) FORMCHECKBOX Limited cognition (unrelated to demyelination or predates demyelination) FORMCHECKBOX N/A (patient is too young for school) FORMCHECKBOX UnknownVaccinationsTable for Vaccination RecordsVaccineDid patient receive this vaccine?Hospitalized?Routine: Measles, mumps, rubella FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Not Asked FORMCHECKBOX Yes, specify: FORMCHECKBOX NoRoutine: Tetanus, pertussis, diptheria, polio FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Not Asked FORMCHECKBOX Yes, specify: FORMCHECKBOX NoHepatitis B FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Not Asked FORMCHECKBOX Yes, specify: FORMCHECKBOX NoHaemophilus Influenza Type B FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Not Asked FORMCHECKBOX Yes, specify: FORMCHECKBOX NoChicken Pox Vaccine FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Natural infection, specify age: yrs FORMCHECKBOX Unknown FORMCHECKBOX Not Asked FORMCHECKBOX Yes, specify: FORMCHECKBOX NoVaccination within one month of 1st demyelinating attack FORMCHECKBOX Yes, specify: FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Not Asked FORMCHECKBOX Yes, specify: FORMCHECKBOX NoGeneral InstructionsNOTE: This CRF only includes data points unique to the pediatric MS population OR data elements phrased differently for a pediatric MS population.This CRF can be completed by self-report with or without verification by a clinician or from clinical records.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Cognitive – Complete according to last year in education and utilize grades reported on report cards from the past year.Vaccinations – Record from vaccination record where possible. For vaccines which require more than one immunization, yes refers to completion of all immunizations required for participant/subject’s current age. ................
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